Midwifery Model of Care—Phase II: Newborn Careby Alyssa Martin

Jan Tritten and Carol Gautschi stated in their recent article, "Midwifery Model of Care—Phase II" (Midwifery Today, Issue 76, Winter 2005), that midwifery care "rests upon the foundation of 'First do no harm.' " Midwives trust the process of birth and strive to allow it to unfold naturally, with little unnecessary management or manipulation. It would follow then that midwives also trust the process of newborn adaptation to respiratory life and strive to allow it to unfold just as the birth has, naturally and harmlessly. However, I question whether the accepted treatment of the newborn during the first few moments after the birth can be considered "harmless" care.

In much of my midwifery training and career, I have both participated in and witnessed countless births in which the energy in the room is palpable as the care providers wait for that first newborn breath to occur. While attending births, I have observed an increase in adrenaline and concern as I anticipate that first breath of the newborn baby. Stated plainly and simply, I want the baby to breathe. The sooner the baby breathes, the sooner I know that that baby's transition is most likely complete. With that first breath, a weight on my shoulders is lifted and I have one less major step in the birth process to worry about. As I look deeper into this reasoning, I realize that my thinking is flawed. Most babies, when left alone, will breathe shortly after birth. Further, a baby will generally breathe on his or her own without any manipulation by me. Do I not trust this to be true?

As stated in the article, "International Guidelines for Neonatal Resuscitation: An Excerpt From the Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science," "approximately 5% to 10% of the newly born population require some degree of active resuscitation at birth (e.g., stimulation to breathe)." According to this statistic, if I attend 20 births per year, one or two of those newborns will require some form of active resuscitation or even stimulation to take that first breath. Why, then, do I experience nervous anticipation as well as the urge to help all newborns along? What is my discomfort with those anticipatory moments shortly after the birth? If I truly trust this process, then why do my actions not support my belief that newborn adaptation to respiratory life will proceed as normal? Do I not fully understand that a baby will, under most circumstances, breathe?

Even with this understanding, I feel challenged to change my habit. In an attempt to embody the truth that birth and newborn transition are normal, I recently began committing to leaving my hands off the baby during the immediate moments after the birth, when appropriate. I was quickly reminded that a baby's condition can be assessed in many ways without much handling. The most important assessment tools I have are my senses.

First is my aural sense. I can hear a baby breathe. I can certainly hear a baby cry. A crying baby is a breathing baby. A snorting baby is also a breathing baby. Sometimes snorts are a sign that baby needs attention or a little bit of assistance from me with clearing the nasal passages.

I also use my sense of sight. I can see the rise and fall of a baby's chest. I can see a change in color of a baby's skin from blue to pink. I can see the expression on the baby's face. I can see either calm or concern on the face of a mother who is deeply in tune with her baby.

Another important assessment tool is my intuition, an extension of my five senses. How do I feel being in the presence of this baby? I will note the cues this baby gives me rather than follow a habitual pattern of actions that may not be of benefit to every baby. If all those methods fail and I still am uncertain about the transition this baby is making, I may use a stethoscope or gently place my hand on the baby's chest. With these two actions, I can either hear the sound of respiration in the lungs or feel the rise and fall of the baby's chest. I am not forcing the baby to take a breath due to my own impatience. I am simply observing the natural process that this baby takes as it enters the world and am determining if anything is truly needed from me.

I might even carry this one step further. If I too quickly or thoughtlessly cover a baby with a blanket and hat, am I affecting an opportunity to truly allow the baby to transition into this world on its own? My experience has been that a complete hands-off approach in the moments after the birth leads to an entirely different reaction from both mother and baby. A mother reacts differently to a baby covered in cloth when she can see only a small section of the newborn's face than to baby who is completely there for her to see and touch. Instead of the midwife, the mother often provides gentle stimulation with her voice and hands to welcome her new baby when she can see and touch its entire body. The mother warms the baby by keeping the baby close to her, submerging the body of the baby in water or asking for a blanket. By seeing and touching her baby, the mother also knows that her baby is safe and healthy and she less often turns to me, her midwife, for reassurance. Babies, under the touch of their mother or father only, transition effectively and quietly into this world in a way that is neither forced nor manipulated.

I suggest that by interrupting a natural process by disturbing or covering a baby in the immediate moments after birth, we are lessening the confidence of a mother to urge her baby to take its first breath. Perhaps by taking over at this moment and not allowing things to unfold naturally, we are in essence disempowering this bonded pair, the motherbaby, and saying instead that we are in control. This does not represent normal birth or even supportive care when viewed in this light. By acting in this way, are we doing harm?

Some may view my hands-off treatment of the newborn in the immediate moments after birth as irresponsible. Indeed, as a midwife, I am usually hired to attend a birth in order to facilitate a healthy delivery and transition for both mother and baby. With this, is my job to stand back when things appear normal or is my job to force the "normal" to occur as soon as possible? While I find that I prefer to delay the covering of a baby with a towel or blanket, I would not encourage this practice under certain circumstances, such as birthing in an extremely cold environment. While I choose to suction as little as possible, I also see the benefits of a bulb or DeLee suction from time to time. While I realize that most babies normally take their first breath on their own and in their own time, I also recognize that some do not. In these circumstances, acting quickly and decisively to help a baby with this process is imperative.

Treating all babies as if they may not breathe because from time to time some do not, however, does not logically follow. To treat all babies as if they may not breathe is often seen as a harmless action that works to the benefit of those few newborns requiring resuscitation. However, blindly stimulating, suctioning and covering all babies may significantly disrupt the perfectly designed process of normal newborn adaptation and bonding. At this moment, I feel the more natural action is to stand back, observe and allow a newborn baby to find its own time to take that first breath, naked and in the arms of its mother. For me, this is the essence of midwifery care and the path of "doing no harm."

Alyssa Martin, CPM, LDM, is currently on a year-long sabbatical from her midwifery practice in Ashland, Oregon. While traveling on sabbatical, she is hoping to deepen her understanding and practice of midwifery.

References:

Newmeyer, S., et al. 2000. International Guidelines for Neonatal Resuscitation: An Excerpt from the Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: International Consensus on Science, Pediatrics 106(3): e29.